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Pharmacotherapeutics Theory 2 > Gastrointestinal Disorders > Flashcards

Gastrointestinal Disorders Flashcards

1
Q

What is Inflammatory Bowel Disease (IBD)?

What is the Age of Onset?

A
  • Idiopathic, chronic, relapsing and remitting inflammation of the GIT (periods of active disease and dormant disease)
  • Age of onset: in the 20s
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2
Q

What is IBS?

2 or more of what criteria?

A
  • Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with 2 or more of the following criteria:
    • Related to defecation
    • Associated with a change in the frequency of stool
    • Associated with a change in the form (appearance) of stool
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3
Q

Should patients worry about the symptoms of IBS?

A
  • Patients are often troubled by these symptoms but they do not lead to more serious outcomes
    • Therefore, don’t necessarily require treatment
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4
Q

What are Alarm Symptoms that a patient might describe in GID?

A
  • Blood in stools
  • Unexplained weight loss
  • Fever
  • Severe abdominal pain
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5
Q

What are the 2 Categories of IBD?

A
  • Crohn’s Disease
  • Ulcerative Colitis
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6
Q

For Crohn’s and Ulcerative Colitis, what is the site of disease and pattern of inflammation?

A
  • Site of Disease
    • CD: Anywhere in GIT (from mouth to anus)
    • UC: Colon only
  • Pattern of Inflammation
    • CD: Patchy – parts of bowel involved, some not involved (discontinuous)
    • UC: Begins at rectum, then ascends up colon (continuous)
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7
Q

For Crohn’s and Ulcerative Colitis, what are the symptoms?

A
  • CD:
    • Symptoms are more heterogenous due to variation in disease location/extent
    • Abdominal pain, diarrhoea (can be bloody), weight loss (including nutritional deficiencies, malabsorption)
    • Systemic symptoms of malaise, anorexia or fever are more common than in UC
    • Intestinal obstruction due to strictures, fistulae or abscesses
    • Might have extraintestinal symptoms (skin, eyes, joints, blood clots) à require management
  • UC:
    • Significant bloody diarrhoea, may become anaemic
    • Urgency as disease progresses
    • Abdominal pain/discomfort could be due to constipation or loading or may represent toxic megacolon during severe flares
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8
Q

What are the types of test that are conducted when diagnosing a patient with IBD?

A
  • Faecal Calpro
    • Performed on the stool sample
    • Measures protein that’s released from neutrophils = marker of inflammation of GIT
  • Colonoscopy/Sigmoidoscopy
  • MRI/CT/Ultrasound
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9
Q

What are the scoring tools used to assess the severity of UC and CD?

A
  • Crohn’s Disease
    • Harvey Bradshaw Index
    • Crohn’s Disease Activity Index
  • Ulcerative Colitis
    • Mayo Score
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10
Q

What are the Goals of IBD Treatment?

A
  • Treat acute disease
    • Reduce or control intestinal inflammation and if possible heal the mucosa
      • Eliminate symptoms (abdominal pain, diarrhoea, rectal bleeding)
      • Prevent complications, hospitalisation and surgery
      • Improve and maintain the patient’s general wellbeing
    • Decrease the frequency and severity of recurrences of the disease
      • Maintain steroid-free remissions and decrease reliance on steroids
    • Correct nutritional deficiencies
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11
Q

The medical management of IBD is determined by what?

A
  • Location of inflammation within the GIT
  • Degree of involvement
  • Severity of symptoms
  • Extra-intestinal complications
  • Response or lack of response to previous treatment
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12
Q

What are the 2 Phases of IBD treatment?

A
  • Induction Phases (get under control)
  • Maintenance Phases (prevent relapse)
    • Patients may relapse when in maintenance
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13
Q

Describe the potential use of allopurinol in patients taking azathioprine to manage hepatotoxicity

A
  • Azathioprine has a risk of hepatotoxicity
  • The hepatotoxicity is caused by 6-MMP (if high levels, risk of developing hepatotoxicity)
    • Concentration of 6-MMP concentration is reduced by using allopurinol
  • 6-TGN = active metabolites (how the drug works)
  • If you use allopurinol, you block Xanthine Oxidase and therefore 6-TGN concentration increased by using allopurinol
  • Using allopurinol with azathioprine is based upon adjustment of the azathioprine dose, to ensure that the 6TGN concentration remains in the right range (Target Concentration)
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14
Q

TDM is increasingly being used to improve the use of the biologics, particularly infliximab. What is it useful for?

A
  • TDM helpful in guiding some of the decision making – try to assess if someone is losing response and what is the reason for this?
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15
Q

TDM: If good concentrations of infliximab and no anti-drug antibodies?

A
  • Tells us drug isn’t working anymore. For whatever reason, the disease is being driven by a pathway independent of TNFa
    • There’s enough drug in the system for it to be working, and there’s no anti-drug antibodies to stop it from working à can switch from infliximab to vedolizumab (targets different pathway, no point swapping to adalimumab as it just targets TNFa
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16
Q

TDM: If low concentrations of infliximab WITH anti-drug antibodies?

A
  • No point increasing the dose
  • Switch from infliximab to adalimumab, because the immune system won’t recognise adalimumab
17
Q

TDM: If low concentrations of infliximab WITHOUT anti-drug antibodies?

A
  • Increase dose (either mg/kg or shortening interval from 8wks to 6wks)
18
Q

Is each individual treatment the same in UC?

A
  • Treatment can vary between patients because treatment is different depending on where in the intestine it is
19
Q

Describe the importance of drug formulation to the management of IBD both in terms of topical treatments and oral

  • Enemas:
  • Foams:
  • Suppositories:
  • Oral Products:
A
  • Formulation depends on which location of the GIT is involved
  • Enemas: reaches up much higher – distal colitis
  • Foams: sprayed in and penetrate up – distal colitis
  • Suppositories: deliver agent to area – proctitis (lower end of rectum)
  • If upper part of GIT, rectal products won’t reach = oral products
20
Q

Describe the importance of drug formulation to the management of IBD both in terms of topical treatments and oral

  • Oral Mesalazine Formulations
    • Mezavant XL (multimatrix system)
    • Pentasa (ethylcellulose-coated microgranules)
    • Salofalk (Eudragit-L coated tablets)
A
  • Mezavant XL (multimatrix system)
    • Doesn’t release until certain pH and slowly releases its contents over time
  • Pentasa (ethylcellulose-coated microgranules)
    • CR formulation gradually release mesalazine over time
  • Salofalk (Eudragit-L coated tablets)
    • EC. Released at pH > 6 once it transitions through the stomach into intestine. Once pH reaches 6, it dumps its dose
21
Q

What may some IBD patients require?

A
  • Some IBD patients will require bowel resection and may have a colostomy/ileostomy
22
Q

What are 2 Potential Complications of Colostomy/Ileostomy?

A
  • High volume liquid stoma output
  • Short bowel syndrome
23
Q

Complications of Colostomy/Ileostomy: What can High Volume Liquid Stoma Output result in and how is it managed? Who may play a role in this?

A
  • Can result in leakage or metabolic disturbances
  • Managed with high dose loperamide
    • Titrated to effect but may be up to 24mg qid
      • Some use of codeine and some patients require octreotide
  • Dietician role in oral fluid and dietary intake as patient is losing a lot of nutrients
24
Q

Complications of Colostomy/Ileostomy: What does Short Bowel Syndrome Depend on and what is there a potential for?

A
  • Depends upon how much bowel is removed and from where
  • Potential for poor absorption of medicines and nutrients
    • Preference for dispersible formulations and liquids
      • Tablets may need to be crushed
25
Q

What can IBD cause (think blood)?

How is this managed?

What is the treatment?

A
  • Anaemia common in IBD. Caused by iron deficiency and chronic inflammation
    • Chronic blood loss, inadequate nutrient intake or absorption
  • At least an annual haemoglobin check
    • As there is inflammation, ferritin alone isn’t reliable
    • Transferrin saturation
    • CRP
  • Treatment may be with oral iron if tolerated or IV (oral iron ferrous sulphate 200mg up to bd)
    • IV preferred when
      • Iron deficiency is severe
      • Significant anaemia is present
      • Active inflammation is present
26
Q

Are the treatments for IBD safe in pregnancy and breast feeding?

A
  • Most agents safe in pregnancy and breastfeeding
  • Allopurinol – safety uncertain in pregnancy
  • Vedolizumab – limited data but likely to be safe in pregnancy and breastfeeding
27
Q

Azathioprine in IBD in Pregnancy

  • What is there concern for?
  • Congenital abnormalities?
  • Prematurity?
  • Lower birth weight?
A
  • Maybe some concern for neonatal anaemia
  • Monitor blood count and baby
  • Incidence of congenital abnormalities after in utero exposure to thiopurines
    • Relatively safe in pregnancy
    • Won’t significantly cause malformations
  • Incidence of prematurity (37 weeks’ gestation) after in utero exposure to thiopurines
    • More likely to have premature baby
  • Incidence of low birth weight after in utero exposure to thiopurines
    • Yes, lower birth weight
28
Q

Biologics in IBD pregnancy

  • What is there a risk for?
  • To the antibodies transfer to the baby?
A
  • Potentially increased risk of infection in the baby
  • Antibodies do transfer to baby via FcRn, however, process isn’t really occurring early on (during high risk period) and therefore baby is exposed. Increased infection risk
  • These drugs have long half-lives, the risk of infection is going to persist for some time after the baby is born
29
Q

What are the Subtypes of IBS?

A
  • Classified into four subtypes based on the patient’s reported predominant bowel habit on days with abnormal bowel movements
    • IBS with predominant constipation
    • IBS with predominant diarrhoea
    • IBS with mixed bowel habits
    • IBS unsubtyped
30
Q

Describe the different treatments in IBS

What about for abdominal pain?

A
  • Dietary modification
    • Increased fibre
    • Low FODMAP
  • Laxatives: may cause cramping and pain
  • Loperamide
  • Abdominal pain
    • Peppermint oil capsules
      • Studies shown that it does help reduce abdominal pain and general improvement
    • Hyoscine butylbromide
    • Mebeverine
    • Iberogast
      • Evidence to show it is helpful
31
Q

What are the 2 most important risk factors in PUD and upper GI bleeding?

A
  • H. Pylori and NSAIDs are the two most important risk factors in PUD and upper GI bleeding
32
Q

PUD:

In patients presenting with upper GI symptoms, choice between what treatments and tests?

A
  • Empirical therapy
    • Usually with acid suppression therapy for possible GORD
  • Urea breath test
  • Endoscopy
    • Particularly if
      • Alarm symptoms:
        • Anaemia, dysphagia or odynophagia, haematemesis and/or melaena, vomiting, weight loss
33
Q

Describe the importance of timing of a repeat h pylori breath test with regards to cessation of antibiotics and PPIs

A
  • Confirmation of Eradication
    • Post-treatment testing is best done with a urea breath test
      • To minimise the chance of false-negative results
        • At least 4 weeks after stopping abx and bismuth
        • PPI therapy should be withheld for at least 1 week (preferably 2 weeks) so you don’t get a false negative
34
Q

What is Diverticulitis?

A
  • Outpouchings in wall of GIT become inflamed and can rupture and release intestinal contents into sterile abdominal cavity = significant medical emergency

Pharmacotherapeutics Theory 2 (17 decks)

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